Abstract

Introduction
In 2003, 11.2% of U.S. households were at some time food insecure; in 1999, when this study was conducted, 10.1% of U.S. households were at some time food insecure.
A previous study of individuals from an Appalachian Ohio county suggested that
food insecurity is associated with poorer self-reported health status. This
larger study assesses the relationship of food security to clinical measurements of several chronic health risks among residents in six rural Appalachian Ohio
counties.

MethodsData for this report are a subset of data gathered by surveys completed by 2580 individuals at community-based sites and by on-site, limited clinical health assessments conducted with a subsample of 808 participants. Descriptive statistics were calculated to describe the sample. Student t tests were used to compare measured BMI, diastolic blood pressure, total cholesterol, random blood glucose, HbA1c levels, and hemoglobin between individuals from
food-secure and food-insecure households.

Results
Our sample had about three times the level of food insecurity (with and without hunger) and more than seven times the level of food insecurity with hunger
as the state population. Diastolic blood pressure, total cholesterol, random blood glucose, HbA1c, and hemoglobin did not differ by food security status (P > .05 for all); however, BMI was greater among
individuals from food-insecure households,
especially among women (t1272 = −2.0, P = .04), than among their food-secure counterparts. Obesity was greater among individuals from
food-insecure households (48.1%) than among those from food-secure households (35.1%, P < .001).

ConclusionThis study examines possible causes and consequences of food insecurity as it relates to chronic disease development. Further investigation is needed
in this community and in other Appalachian communities, as well as the United States,
to determine relationships between food insecurity and chronic disease development and management.

Introduction

Food security means having access, at all times, to enough food for an active, healthy life without resorting to
using emergency food supplies, begging, stealing, or scavenging for food. Conversely,
food-insecure individuals and families have limited access to or availability of food or a limited or uncertain ability to acquire food in socially acceptable ways (1).
In 2003,
11.2% of U.S. households were at some time food insecure (2); in 1999, when this study was conducted, 10.1% of U.S. households were at some time food insecure (3). Overall, households in rural areas experienced more food insecurity than those in metropolitan areas (2,3).

Healthy People 2010 includes the objective of increasing food security among U.S. households (4). Food insecurity can have negative consequences on health
(5-9) and may cause physical impairments, psychological
effects, and sociofamilial disturbances (10). For adults, food insecurity or insufficiency has
been associated with lower dietary intakes of essential nutrients (11-14), fruits
and vegetables (12,13), and milk and milk-based products (12) in addition to
less-healthy diets (15). Over time, these suboptimal intakes could increase
individuals’ risk of developing diet-related chronic diseases (12). Food insecurity has
also been associated with poor disease management in adults with
chronic diseases, including diabetes (5-9,12,16-18).

Food insecurity among adults has been associated with being overweight or
obese (19), especially among women (20-26). The relationship
of obesity and food insecurity may be related to the low cost of energy-dense
foods and reinforced by the pleasing taste of sugar and fat (27); however,
food-insecure women do not seem to consume more high-fat, high-sugar, empty-calorie foods
than their food-secure counterparts (28).
Periods of overeating when food is available, including binge-like patterns of
eating (13) or fluctuations in eating habits that promote a metabolic-adaptive
response, may also account for overweight and obesity among adults from
food-insecure households.

Pheley et al (6) found that individuals living in
food-insecure households in a rural Appalachian Ohio community reported
significantly worse functional health status than their food-secure counterparts, which was measured by the Medical Outcome Study Short Form-36 (SF-36)
(29) and the 18-item U.S. Household Food Security Survey Module (FSSM) (30). To further investigate the health status and chronic
disease risks of the community, we conducted a larger study. As part of this
study, we assessed the relationship
between food security and clinical measurements of several chronic health
risks, including those that can contribute to obesity and diabetes.

The study area comprised some of the most impoverished counties of Ohio. Since 1980, rural regions
in southern Ohio have lagged behind the rest of the nation in economic performance (31).
Poverty is higher in rural Appalachia than in other regions, especially in southern Ohio (32). Because of the cost of developing roads, communication systems, public works facilities, and other infrastructure, health care delivery is often
cost prohibitive. These limiting factors are present to an even greater extent in Appalachian areas than in other rural
areas. Barriers to travel
in inclement winter weather and flooding during early spring further complicate these
factors.

Methods

All study procedures were reviewed and approved by the Ohio University Office of Research Compliance before the collection of any data. Data for this
article are a subset of data gathered to examine the relationship
among self-described health status, access to and use of health care, and other personal characteristics of rural community-based participants. Specifically, we assessed the
following variables: 1) self-reported household food security status; 2) self-reported
diabetes; 3) BMI; 4) diastolic blood pressure; 5) total cholesterol; 6) random
blood glucose; 7) hemoglobin
A1c (HbA1c); and 8) hemoglobin. We also analyzed the relationship among these factors.

Household food security categories (food secure, food insecure with and without hunger, food insecure without hunger, food insecure with hunger [both moderate and severe]) were based on
the FSSM. Overweight was categorized as
a BMI of 25 kg/m2 or higher but less than 30 kg/m2, and obesity was categorized
as a BMI higher than or equal to 30 kg/m2
(19). HbA1c levels less than 7% were considered to be within recommended ranges.

Setting and participants

This study was conducted in Athens, Hocking, Meigs, Perry, Pike, and Vinton counties in Ohio. These rural counties are in the northern Appalachian region of the United States (32,33). The U.S. Department of Agriculture’s Economic Research Service has designated Athens and Vinton counties as
high poverty because they have a poverty rate
of 20% or more (34) and, based on the economic indicators of unemployment rates, per capita income
level, and poverty (32), the Appalachian Regional Commission (ARC) has classified Athens, Meigs, Pike, and Vinton counties as distressed, which is the most severe economic level category.
Perry and Hocking are categorized by the ARC as transitional counties, that is,
counties that are at
risk of becoming distressed. Table 1
provides demographic characteristics of the population in these counties.

Participants were recruited from the following community sites: 1) fairs and
festivals; 2) food distribution programs for low-income families; 3) churches;
4) senior centers; 5) community action agencies and other programs offering
services to families with limited resources; and 6) general sites, including
grocery stores and shopping malls. From these convenience samples, 2580 adults
aged 18 and older completed the study survey.

Survey

From June through August 1999, research teams of 8 to 12 individuals set up tables and signage at the
31 study sites and invited people to complete a survey. All participants were provided a clipboard, a 12-page survey, and a pencil. Assistance was provided to participants who could not read or otherwise requested help in completing the questionnaire. When the participants completed the surveys, the surveys were
reviewed on-site by project staff for completeness and legibility. The survey included demographic questions, information about the respondent’s access to and use of health care, comorbid health conditions, and other validated measures
(SF-36 [29] and FSSM [30]). Participants were provided a $5.00 gift certificate to a local grocery store as
compensation for their time and effort.

Clinical examination

After they completed the survey, 808 participants (31.3%)
agreed to undergo an on-site, limited clinical health examination. After these
clinical health examination participants gave their written informed consent, they underwent an examination,
regardless of their self-reported diabetes status. The components of the
examination are described in Table 2 (38).

The devices used to measure biochemical indices were Clinical Laboratory Improvement Amendments (CLIA)-approved or
waived (36). Each device was calibrated twice per day (once before morning sessions and again before afternoon sessions) according to manufacturer directions and commercial control solutions, except for the DCA 2000 (Bayer, Inc, Tarrytown, NY), which
was calibrated after each series of 10 assays. Capillary blood collection and operation of the
associated devices were conducted by second-year medical students under the supervision of the on-site physician. Each operator received
2 days of extensive training before the project began; staff evaluations and retraining were conducted throughout the study period.

Clinical health assessment participants were given an additional $5.00
grocery store gift certificate for their time and effort. Test results were
provided by project staff to participants and to the physician or clinic
identified by participants as their primary care provider. If the participant did not identify a primary care provider, the extra copy of the results was given to the
individual. Participants were given the opportunity to speak with an on-site physician about any abnormal values. Although critical threshold values requiring immediate treatment for each of the screening tests were established before the study began, no individuals were identified
who exceeded these criteria.

Data management and analysis

All survey data were entered electronically using a key-and-verify model to minimize data transcription errors and enhance data integrity. All analyses were conducted using the SPSS, version 10.0 (SPSS,
Inc, Chicago, Ill). Descriptive statistics were calculated to describe the
sample. Chi-square analysis was used to compare self-reported diabetes, obesity, and HbA1c levels greater than 7% between
participants from
food-secure and food-insecure households. Finally, Student t tests were used to compare measured BMI, diastolic blood pressure, total cholesterol, random blood glucose, HbA1c levels, and hemoglobin between individuals from
food-secure and food-insecure households. P values (a = .05) are
reported to communicate the strength of the relationships measured.

Results

Table 3 describes the characteristics of the 2580 adults who completed the survey. Table 4 summarizes household food security status of our sample during the 12 months before sampling compared with the
state- and national-level estimates of household food security status at the time of the study.
It also shows that our sample had about three times the level of food insecurity
(with and without hunger) and more than seven times the level of food insecurity
with hunger as the state population. Of those participating, 1879 (72.8%) were
from food secure households and 701 (27.2%) were from food insecure with and without hunger
households. Of the
total number of participants, 183 (7.1%) were from households classified as food insecure without hunger, and 518 (20.1%) were
from households classified as food insecure with hunger. (Food insecurity with hunger included those classified as food insecure with moderate hunger [n = 248, 9.6%] and food insecure with severe hunger [n = 270, 10.5%].)

Table 5 summarizes the clinical health
examination results by food security status and by sex within the food security groups. Overall,
the results were within recommended ranges; the exception was BMI,
which exceeded healthy weight guidelines of 25 kg/m2 or less. Diastolic blood pressure, total cholesterol, random blood glucose, HbA1c, and hemoglobin did not differ by food security status (P
> .05 for all); however, BMI was greater among participants from food-insecure households,
especially among women (t1272 = −2.0, P = .04),
than among their
food-secure
counterparts.

When stratified by sex, only BMI and HbA1c were significantly greater among women from
food-insecure households than among those from food-secure households. For men, only hemoglobin levels were significantly greater among those from
food-secure households than among those from food-insecure households.

Through chi-square analysis, we found that obesity was greater among individuals from food-insecure households (48.1%)
than among those from
food-secure households (35.1%, P < .001), and it increased monotonically
as food insecurity worsened (from food secure to food insecure with hunger)
(data not shown); 35.1% of obese individuals were from food-secure households.
Of those obese individuals who were from food-insecure households, 43.4% were
food insecure without hunger, 47.8% were food insecure with moderate hunger, and
52.4% were food insecure with severe hunger (c2 linear association, P < .001). Additionally, we found that individuals with an HbA1c
level of higher than 7% (33.9%) were more likely (P = .053) to come from
food-insecure households
than respondents with HbA1c levels of less than 7% (22.5%) (data not shown).

Of the 2504 who noted their diabetes status, 298 (11.9%) reported having
diabetes. People who reported having diabetes were
significantly more likely to live in food-insecure households (37.9%) than in food-secure households
(25.8%) (c21
= 19.3, P < .001).

Discussion

This study examines possible consequences of food insecurity as they
relate to overweight, obesity, and chronic disease and highlights the need for further research on health status in the Appalachian region and the United States. The prevalence of food insecurity among this sample was more than 2.5 times the U.S. average rate (10.1%) in 1999 (3) and almost 3 times the Ohio
average rate of household food insecurity at the time of the study (9.1%) (2).

A previous study suggested that even minimal levels of food insecurity are associated with poorer self-reported health status among individuals from an Appalachian Ohio county (6).
Poor health status has also been associated with food insecurity in other
studies (5,7-9). For adults, dietary quality can be negatively affected by food insecurity or insufficiency (11-13,15), and
these suboptimal intakes could increase the public’s risk of developing diet-related chronic diseases over time (12).

In this study, participants from food-insecure households had higher BMIs, rates of obesity, and self-reported
rates of diabetes than those from food-secure households. No difference in food
security status, however, was noted between diastolic blood pressure, total cholesterol, random blood glucose, HbA1c, and hemoglobin. This study is consistent with previous reports in which
overweight or obesity have been associated with food insecurity among adults in rural and other areas of the United States (20-26). Women, unlike men, from
food-insecure households had higher BMIs than those from food-secure households,
a result which is
consistent with national trends (20-26).

For our sample, the self-reported rate of diabetes (11.9%) was greater than the 2002 national average for adults
aged 20 years and older (8.7%) (40); those reporting to have
diabetes were more likely to reside in food-insecure than food-secure households. Likewise,
individuals with HbA1c levels
of higher than 7% were more likely to come from food-insecure households than those with levels
of less than 7%. Although mean HbA1c levels
were within normal ranges for both groups, previous reports cite that household food insecurity has been associated with poor disease management in adults with chronic disease (5,16-18).

Limitations of this study include our sampling strategy. Whereas data for the U.S. estimates are from national probability samples, our
participants were a convenience sample and were not necessarily representative of the region.
Our sampling process limited the generalizability of these data. A comparison of Census 2000 data (35)
with our sample suggests our sample is more racially diverse, is somewhat
overrepresented by women, includes fewer individuals without a high school
education, and has a lower income than is typical of the counties where the sample was drawn. However, our data are consistent with trends previously reported
and provide evidence of the possible health consequences of food insecurity.

Another limitation of this study was the use of nonfasting blood measurements;
fasting measurements were
prohibited by the nature of the sampling process. Although standards and reference values for laboratories differ, HbA1c and hemoglobin reference values for adults are generally nonfasting, and total cholesterol and random blood glucose are typically fasting, because values can be falsely increased without fasting.
Even with this limitation, the total cholesterol and random blood glucose
measurements were within recommended ranges.

This study examines possible causes and consequences of food insecurity as it relates to chronic disease development. Further investigation is needed
in these and other Appalachian communities and throughout the United States to
determine the relationship between food insecurity and chronic disease development and management. To improve outcomes associated with
food insecurity (e.g., obesity, diabetes, poor disease management), dietetic,
nutrition, medical, and community and public health professionals should
incorporate food-security–related strategies into their practices (41,42).
Furthermore, alleviating food insecurity in the United States seems contingent
upon adequate funding and increased use of food and nutrition assistance programs; inclusion of food and nutrition education in all programs providing food and nutrition assistance to the public; and
development of innovative programs to promote and support economic self-sufficiency of individuals, families, and households (43).

U.S. Department of Health and Human Services. Healthy people 2010. Objective 19-18. Increase food security among U.S. households and in so doing reduce hunger
[Internet]. Washington (DC): U.S. Department of Health and Human Serivces. Available from: URL: http://www.healthypeople.gov/document/html/ objectives/19-18.htm.

Centers for Disease Control and Prevention. BMI for adults [Internet].
Atlanta (GA): Centers for Disease Control and Prevention;[cited 2005 Jun 2]. Available from: URL: http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-adult.htm.

Frongillo EA Jr, Olson CM, Raschenbach BS, Kendall A. Nutritional consequences of
food insecurity in a rural New York county (discussion paper no. 1120-97). Madison
(WI): Institute for Research on Poverty, University of Wisconsin-Madison; 1997.

Measured to the nearest
milligram per deciliter (mg/dl) using a cholesterol meter; device calibrated twice each day using commercial control solutions according to manufacturer directions (Roche, Accu-Chek Instant Plus Monitor Model, Basel, Switzerland)

Random glucose

Measured to the nearest
milligram per deciliter (mg/dl) using a glucose meter; device calibrated twice each day using commercial control solutions according to manufacturer directions (LifeScan, Inc, One-Touch Profile Blood Glucose Monitor, Milpitas, Calif)

HbA1c

Measured to the nearest .01%; device calibrated after every 10 assays using commercial control solutions according to manufacturer directions (Bayer, Inc, DCA Model 2000, Tarrytown, NY)

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